Gur u Speak
Role of physiotherapy in acute burns
Downloaded from http://journals.lww.com/ijob by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
INTRODUCTION
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 10/15/2023
Burn injuries are often associated with devastating physical,
functional, and psychological sequelae such as hypertrophic
scarring, formation of contractures, joint deformities, and
emotional disorders. It is a challenge to reintegrate these
patients into the society making burns a forerunner among
health problems that result in disability‑adjusted life years
lost in low‑ and middle‑income countries.[1] Therefore, the
treatment focus should not only be on wound care but
also on the early functional rehabilitation of the patient.
A Multidisciplinary approach is essential for the optimal
recovery of a burn patient and physiotherapy should be
an integral part of the burn treatment protocol. Early
commencement of physiotherapy right from the day of
admission has multifold benefits and plays a key role in
early functional recovery of the burn patient. Although
physiotherapy rehabilitation is a continuous process,
we, in this article highlight its role in the acute phase of
burns.
BENEFITS OF EARLY INITIATION OF PHYSIOTHERAPY
Successful integration of the physiotherapy protocol with the
medical and surgical treatment of burn injuries is of utmost
importance. Early start of physiotherapy intervention with
clearly defined objectives [Table 1], from the day of admission
is highly beneficial for the patient.[2,3]
a. The acute phase in major burns is marked by extensive
fluid shifts resulting in generalized edema. Edema fluid
can lead to increase in the depth of the burns and also
causes the limbs to be placed in the position of comfort
that ultimately leads to deformities [Figure 1a and b].
Proper limb positioning and elevation encourage drainage
Access this article online
Quick Response Code
Website:
www.ijburns.com
DOI:
10.4103/ijb.ijb_3_23
© 2023 Indian Journal of Burns | Published by Wolters Kluwer - Medknow
of fluid in the acute phase. In the long run, physiotherapy
interventions may also prevent joint deformities and
contractures, thus, also reducing the cost of treatment
by avoidance of subsequent surgeries for such post‑burn
sequelae[4‑6]
b. There is also an inflammatory response within a few hours
of injury, which is characterized by a rise in the levels of
pro‑inflammatory cytokines and acute phase reactants.
Immune dysregulation and hypermetabolism are also
associated with burn injuries which cause decreased lean
muscle mass and delayed wound healing. Early initiation
of physiotherapy has been shown to mitigate some of the
hypermetabolic responses associated with burn injury
reflected by significantly increased values of biochemical
markers, such as fibronectin, transferrin, and prealbumin
in those who receive physiotherapy versus the control
group within a few weeks after burn injury.[7]
CHALLENGES FACED
The acute phase of burns is critical for the patient as well
as the medical professional. There are various emotional,
psychological, and physical barriers that need to be overcome
to facilitate early physiotherapy in the following phase.[8‑10]
Sunil Sharma, Deepti Gupta
Department of Burns, Plastic and Maxillofacial Surgery,
Safdarjung Hospital and Vardhman Mahavir Medical College,
New Delhi, India
Address for correspondence: Dr. Deepti Gupta,
Department of Burns, Plastic and Maxillofacial Surgery, Safdarjung
Hospital and Vardhman Mahavir Medical College, New Delhi, India.
E‑mail: deepti2611@gmail.com
Submitted: 16-Jan-2023, Accepted: 22-Jan-2023,
Published: 14-Jun-2023
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
is given and the new creations are licensed under the identical terms.
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
How to cite this article: Sharma S, Gupta D. Role of physiotherapy in
acute burns. Indian J Burns 2022;30:1-5.
1
 Sharma and Gupta: Physiotherapy in burns
Table 1: Objectives of physiotherapy intervention during the
acute phase of burns[2,3]
Edema reduction
Respiratory system
Clearing the airways of secretions
Optimizing lung compliance and pulmonary ventilation
Decrease work of breathing
Downloaded from http://journals.lww.com/ijob by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
Increase exercise tolerance
Musculoskeletal system
Maintenance of ROM
Maintenance of joint alignment and prevention of deformities
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 10/15/2023
Prevention of contracture formation
Assistance and strengthening of weak muscles
Promote healing
Deep venous thrombosis prevention
Prevention of pressure sores
ROM: Range of motion
Emotional
The patient is going through a myriad of emotions to fully
understand the physical and functional implications of the
burn injury sustained. The social stigma attached with
postburn disfigurement also leads to feelings of fear and
anxiety in the patient. There is a need to understand the
emotional needs and to build a trusting relationship with the
patient to achieve voluntary participation in the rehabilitative
process. Grief counseling before the physiotherapy sessions
also aids in improving the emotional state of the patient.
Lack of motivation
Patients are often reluctant to undergo any kind of
physiotherapy as they are already overwhelmed by the nature
of the injury. They are also not aware of the benefits and the
long‑term gains that they can achieve with physiotherapy.
It is important to educate them and their family members
regarding the importance of this process and how it allows
them to be independent and lead their life with integrity. It
is also essential to prepare them for a long journey that lies
ahead of them.
Pain
Physical pain is often the biggest hindrance to rehabilitative
interventions. The physiotherapy process includes stretching
and movements, which inflict further pain on a pre‑existing
painful condition. This causes the patient to further become
apprehensive and deny any intervention that may increase
the pain. Adequate pain control is, therefore, of utmost
importance to allow the patient to actively participate in
the physiotherapy program. Various analgesic drugs such
as paracetamol, nonsteroidal anti‑inflammatory drugs, and
opiates along with transcutaneous electric nerve stimulation
are used to this effect.
2 Indian Journal of Burns / Volume 30 / Issue 1 / January-December 2022
a b
Figure 1: (a) Claw hand deformity because of prolonged maintenance of
‘position of comfort’ in patients with dorsal hand burns, (b) In patients with
involvement of axillary region, keeping the shoulder adducted leads to the
development of axillary contracture
Lack of collaboration
Apart from patient factors, another important obstacle to early
physiotherapy is the late referral by the treating burn physician.
Sometimes, the rehabilitative interventions are delegated to
the background and importance is given only to resuscitation
and burn wound management, However, since holistic recovery
is the goal of treatment in burn injury, a multidisciplinary team
involving the physiotherapist should attend to the patient on
the day of admission and the whole team should work toward
a common goal for the benefit of the patient.
BASELINE ASSESSMENT
Individual needs and the capability to participate in the
physiotherapy process have to be assessed and a meticulous
protocol has to be devised to achieve satisfactory functional
outcomes. A detailed history and clinical examination are
carried out to assess the extent of burns, regions of the body
involved in burns, presence of inhalational injury, or any
concomitant injury such as exposed tendons or bony trauma,
which may impact the rehabilitation. A baseline respiratory,
cardiovascular, and neuromuscular examination is carried out
and recorded for future use. Age and presence of comorbid
conditions also need to be considered when planning the
physiotherapy interventions.
PHYSIOTHERAPY INTERVENTIONS
1. Respiratory system: Prophylactic chest physiotherapy
is started if an inhalational injury is suspected.
Interventions include:[2,11,12]
a. Patient positioning: Propped up position is
maintained with the head of the bed raised at
30°–45° angle. This reduces the abdominal pressure
on the diaphragm and also helps in decreasing upper
airway edema
b. Postural drainage with percussion and vibration:[13]
It involves the positioning of the patient in such
a manner as to allow gravity‑assisted drainage of

Downloaded from http://journals.lww.com/ijob by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 10/15/2023
2.
Figure 2: Electrical device to deliver vibrations for chest physiotherapy
Sharma and Gupta: Physiotherapy in burns
secretions from the involved lobe of the lung. It is
specially indicated for middle and lower lobes. The
foot end is elevated to place the involved lobe above
the carina followed by chest percussion to loosen
the secretions. This is carried out for 5–15 min
every 4–6 h till required. It is usually combined
with percussion and vibration to enhance airway
clearance. Percussion and vibration are techniques
used to loosen and mobilize the thick secretions.
They can be carried out manually with hands or with
the help of electrical devices [Figure 2]
c. Assisted coughing: In patients with muscle weakness
who are unable to clear secretions on their own,
cough can be assisted manually by the application
of pressure over the diaphragm or using a medical
device that applies pressure to the lungs in a manner
that simulates a cough. The objective is to clear the
retained secretions and increase the tidal volumes
d. Breathing techniques:[14] Deep breathing exercises are
taught to the patients for prevention and treatment
of atelectasis. These involve breath holding, pursed
lip breathing, diaphragmatic breathing, and the
use of incentive spirometer [Figure 3]. These
help in keeping the small airways patent, thereby
preventing atelectasis and its complications like
pneumonia
e. Instrumental techniques:[15] Positive expiratory
pressure devices, continuous positive airway
pressure, and intrapulmonary percussive ventilation
are some of the devices that are used as an adjunct
to conventional chest physiotherapy to reopen
collapsed airways and improve lung ventilation.
Edema reduction techniques are best initiated in the first
48 h of burn injury and continue for a longer period if
indicated.
a. Compression with stretchy bandages such as Coban
Indian Journal of Burns / Volume 30 / Issue 1 / January-December 2022
or with edema gloves can be applied to swollen limbs
b. Exercises that provide rhythmic pumping movements
increase the drainage of edema fluid. They are
taught to the patient or can be achieved with the
help of pneumatic compression devices for the
upper and lower limbs [Figure 4].
c. Positioning: [3,16] Gravity‑assisted drainage is
encouraged by the elevation of swollen limbs.
The head end of the bed is elevated to minimize
facial edema. Patients tend to keep their limbs in
a position of comfort which in the long run results
in contractures [Table 2]. It is essential to adhere to
patient positioning protocols to achieve maximal
functional recovery. The required position can be
achieved by tilting the bed, use of foam wedges,
pillows, and by custom‑made orthosis.
3. Immobilization:[3,17,18] Although early mobilization is
preferred, splints are used within the first 24 h in some
special cases to maintain an anti‑deformity position and
prevention of contracture formation. Dorsal hand burns
are one such case in which there is a high propensity of
the development of claw deformity due to dorsal edema
or risk of rupture of extensor tendons in case of deep
burns over dorsal proximal interphalangeal joints. Acute
splinting of the burned hand is done with wrist in 0–30
extension, metacarpophalangeal joints (MCPJs) in 70–80
flexion, and interphalangeal joints (IPJs) in full extension.
The thumb is kept in radiopalmar abduction with MCPJ
and IPJ is mild flexion [Figure 5a and b]. Static splints
can also be used to maintain antideformity position of
the nostrils, mouth, neck, axilla, elbow, hip, knee, and
foot if the need arises [Figure 6a and b]
4. Stretching or range of motion (ROM) exercises: In the
acute phase, active and active assisted movements of the
Figure 3: Incentive spirometer used to teach deep breathing and inspiratory
holds
3
 Sharma and Gupta: Physiotherapy in burns

joints through the full ROM are carried out by the patient individualized according to the capabilities and specific
if he is fully awake and competent. Passive movements needs of the burn patient. Rehabilitation is a continuous
are carried out by the caregiver of the limbs if the patient process that works in tandem with medical and surgical
is critically ill or sedated, to preserve joint mobility and
prevent any restriction of ROM. Manual application of
tension to the skin to attain lengthening or elongation
Downloaded from http://journals.lww.com/ijob by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

can be used to increase ROM

5. Therapeutic exercises:[19,20] The goal of therapeutic
exercises is to return the patient to preinjury functional
state. These include interventions for strengthening of
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 10/15/2023

muscles, building endurance, and improving balance

and coordination. Isometric exercises help in retaining
muscle memory and resistive exercises increase muscle
strength. Exercises performed frequently for a short
span of time are seen to have a favorable outcome.
Early physical therapy preserves muscle strength and
maintains joint mobility thus preventing the formation
of contractures. It is also associated with the prevention
Figure 4: Pneumatic compression device in lower limbs to prevent deep
of cardiorespiratory complications venous thrombosis
6. Ambulation: Mobility is often restricted in patients with
extensive lower limb burns. Bulky dressings along with
interventions in the acute phase such as femoral central
line insertion, Ryle’s tube insertion, tracheostomy,
and Foley’s catheterization; further limit the patient’s
mobility. Ambulation should be started as soon as the
patient is clinically stable. Early ambulation is associated a b
with the preservation of muscle strength, increase in Figure 5: (a) Diagrammatic representation of “position of immobilization”
appetite, prevention of bed sore, and reduction in the for hands, (b) Burned hand immobilized in recommended position with a
incidence of deep venous thrombosis. plaster of Paris slab

SUMMARY

Physiotherapy intervention is an indispensable component

of burn management. It is of utmost importance for the
burn care centers to follow an integrated approach right
from the beginning and involve the physiotherapists in the
treatment of patients, to prevent any unnecessary delay in a b
the initiation of the rehabilitative interventions. To achieve Figure 6: (a) Oral splint to prevent microstomia in patients with oral
maximal outcomes the physiotherapy program should be burns, (b) Aeroplane splint to prevent axillary contracture

Table 2: The common positions of comfort for various body parts involved in burns and the recommended position to prevent
contracture
Area of burn Position of comfort Recommended position
Anterior neck Flexion Neutral or mild extension, no pillow under the head
Posterior neck Extension Flexion
Shoulder Adduction and internal rotation 60°‑90° abduction and external rotation
Elbow Flexion Extension
Wrist Flexion 0°‑30° extension
Digits Thumb adduction, fingers MCPJ extension and IPJ flexion Thumb in palmo‑radial abduction, fingers MCPJs in
70°‑80° flexion and IPJs in extension
Lower extremity Hip flexion, knee flexion, foot plantar flexion Hips neutral, knee in extension, and foot neutral
Face Incomplete closure of eyes, restriction of mouth opening Regular movements, stretching, use of oral splints
MCPJ: Metacarpophalangeal joints, IPJ: Interphalangeal joints

4 Indian Journal of Burns / Volume 30 / Issue 1 / January-December 2022

 Sharma and Gupta: Physiotherapy in burns
management to aid in the optimal comprehensive recovery
of the burn patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
Downloaded from http://journals.lww.com/ijob by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 10/15/2023
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Burns. WHO; 2018. Available from: https://www.who.int/news‑room/
fact‑sheets/detail/burns. [Last accessed on 2023 Jan 15].
2. Patsaki I, Kyriakopoulos A, Katartzi M, Markaki V, Emmanouil P.
Physiotherapy in a burn patient admitted in Intensive Care Unit. Hosp
Chron 2020;15:18‑23.
3. Procter F. Rehabilitation of the burn patient. Indian J Plast Surg
2010;43:S101‑13.
4. Edgar D, Brereton M. Rehabilitation after burn injury. BMJ
2004;329:343‑5.
5. Jacobson K, Fletchall S, Dodd H, Starnes C. Current concepts burn
rehabilitation, part I: Care during hospitalization. Clin Plast Surg
2017;44:703‑12.
6. Gomez M, Tushinski M, Jeschke MG. Impact of early inpatient
rehabilitation on adult burn survivors’ functional outcomes and resource
utilization. J Burn Care Res 2017;38:e311‑7.
7. Çınar MA, Bayramlar K, Erkılıç A, Güneş A, Yakut Y. The effects of early
Indian Journal of Burns / Volume 30 / Issue 1 / January-December 2022
physiotherapy on biochemical parameters in major burn patients: A burn
center’s experience. Ulus Travma Acil Cerrahi Derg 2019;25:461‑6.
8. Dunpath T, Chetty V, Van Der Reyden D. Acute burns of the
hands – Physiotherapy perspective. Afr Health Sci 2016;16:266‑75.
9. Kornhaber R, Wilson A, Abu‑Qamar MZ, McLean L. Adult burn
survivors’ personal experiences of rehabilitation: An integrative review.
Burns 2014;40:17‑29.
10. Esselman PC, Thombs BD, Magyar‑Russell G, Fauerbach JA.
Burn rehabilitation: State of the science. Am J Phys Med Rehabil
2006;85:383‑413.
11. Pathmanathan N, Beaumont N, Gratrix A. Respiratory physiotherapy in
the critical care unit. Contin Educ Anaesth Crit Care Pain 2015;15:20‑5.
12. Keilty SE. Inhalation burn injured and physiotherapy management.
Physiotherapy 1993;79:87‑90.
13. Goñi‑Viguria R, Yoldi‑Arzoz E, Casajús‑Sola L, Aquerreta‑Larraya T,
Fernández‑Sangil P, Guzmán‑Unamuno E, et al. Respiratory
physiotherapy in Intensive Care Unit: Bibliographic review. Enferm
Intensiva (Engl Ed) 2018;29:168‑81.
14. Rodrigues A, Muñoz Castro G, Jácome C, Langer D, Parry SM, Burtin C.
Current developments and future directions in respiratory physiotherapy.
Eur Respir Rev 2020;29:200264.
15. Hristara‑Papadopoulou A, Tsanakas J, Diomou G, Papadopoulou O.
Current devices of respiratory physiotherapy. Hippokratia
2008;12:211‑20.
16. Schnebly WA, Ward RS, Warden GD, Saffle JR. A nonsplinting approach
to the care of the thermally injured patient. J Burn Care Rehabil
1989;10:263‑6.
17. Leman CJ. Splints and accessories following burn reconstruction. Clin
Plast Surg 1992;19:721‑31.
18. Rrecaj S, Hysenaj H, Martinaj M, Murtezani A, Ibrahimi‑Kacuri D,
Haxhiu B, et al. Outcome of physical therapy and splinting in hand burns
injury. Our last four years’ experience. Mater Sociomed 2015;27:380‑2.
19. Mudawarima T, Chiwaridzo M, Jelsma J, Grimmer K, Muchemwa FC.
A systematic review protocol on the effectiveness of therapeutic
exercises utilised by physiotherapists to improve function in patients
with burns. Syst Rev 2017;6:207.
20. Gittings PM, Wand BM, Hince DA, Grisbrook TL, Wood FM,
Edgar DW. The efficacy of resistance training in addition to usual care
for adults with acute burn injury: A randomised controlled trial. Burns
2021;47:84‑100.
5